Our ability to draw effective conclusions about your present state of health and how to improve it depends, to a significant extent, on your ability to respond thoughtfully and accurately to both these written questions and those posed by the clinician during your consultations. Health issues are usually influenced by many factors. Accurately assessing all the factors and comprehensively managing them is the best way to deal with these health challenges. Your careful consideration of each of the following questions will enhance our efficiency and will provide for more effective use of your scheduled consultation time. These questions will help to identify underlying causes of illness and will also assist us to formulate a treatment plan.
First Appointment date: ________________
Name Mr. / Mrs. / Ms. / Dr. _____________________________________________________________
Address ______________________________________________________________________________ Street City State Zip Code
Social Security # ______________________________________ Sex: Male / Female
Birth date _____________________ Age __________ Marital Status: Married / Single
Height: ____’ ____” Weight:________
Home # ( ) _____________ Work # ( ) _________________ Cell # ( ) _________________
Referred by: Physician / Clinician (name, contact) ____________________________________________________ Book Website Media Friend / Family Member Other ____________ Physician: Name ____________________________________________________________________ Phone Number __________________________________ Fax __________________________________ Please List all Allergies: Animal Dander Latex Penicillin Pollen Second-Hand Smoke Grasses Hay Sulfa Drugs Perfumes Dairy Products Food Allergies:__________________________________ Other: ________________________
What do you hope to achieve with your visit today? When was the last time you felt well? What caused the change in your health? What makes you feel worse?
What makes you feel better? If you could erase three problems, what would they be? 1. Please check appropriate box(es):
African American Hispanic Mediterranean Asian Native American Caucasian Northern European Other 2. Please rank current and ongoing problems by priority and fill in the other boxes as completely as possible:
DESCRIBE PROBLEM
MILD/
MODERATE/ SEVERE
TREATMENT
APPROACH SUCCESS
Example: Post Nasal Drip Moderate Elimination Diet Moderate
a.
b.
c.
d.
e.
f.
g.
3. With whom do you live? (Include children, parents, relatives, and/or friends. Please include ages.) Example:
15. List all vitamins, minerals, and other nutritional supplements that you are taking now. Indicate whether mg or IU and the form (e.g., calcium carbonate vs. calcium lactate), when possible.
Vitamin/Mineral/Supplement Name
Date started Dosage
1.
2.
3.
4.
5.
6.
7.
16. Childhood: Were you a full term baby? Yes____ No____ Don’t Know _____ Comments: ____________
17. As a child, did you eat a lot of sugar and/or candy? Yes____ No____
18. As a child, were there any foods that you had to avoid because they gave you symptoms? Yes____ No____ If Yes, please name the food(s) and symptom(s): ________________________________________________ _________________________________________________________________________________________
19. Have you ever used alcohol? Yes____ No____
20. Have you ever had a problem with alcohol? Yes____ No____
If yes, please indicate time period (month/year): from ________ to ___________.
21. Have you ever used recreational drugs? Yes____ No____
22. Have you ever used tobacco? Yes____ No____
If yes, number of years as a nicotine user _____. Amount per day _____. Year quit _____. If yes, what type of nicotine have you used? _____Cigarette _____ Smokeless _____Cigar _____Pipe _____Patch/Gum What kind? ____________________________________________________________________________ Comments: ____________________________________________________________________________
23. Are you exposed to second-hand smoke regularly? Yes____ No____
24. Do you have mercury amalgam fillings? Yes____ No____
25. Do you have artificial joints or implants? Yes____ No____
26. Do you feel worse at certain times of the year? Spring____ Summer____ Fall____ Winter ____ No____
27. Have you, to your knowledge, been exposed to any of the following toxic metals? Yes____ No____
28. If yes, which one(s)? ____ lead ____cadmium ____ aluminum
30. Do you exercise regularly? Yes____ No____ If so, how many times a week? _______ When you exercise, how long is each session? ____________
31. Any other family history we should know about? Yes____ No____ If so, please comment: _______________________________________________________________ 32. What is the attitude of those close to you about your illness? Supportive Non-supportive
33. Place a check mark next to the food / drink that applies to your current diet.
Usual Breakfast Usual Lunch Usual Dinner
a. None a. None a. None
b. Bacon/Sausage b. Butter b. Beans / Legumes
c. Bagel c. Coffee c. Brown Rice
d. Butter d. Eat in Cafeteria d. Butter
e. Cereal e. Eat in Restaurant e. Carrots
f. Coffee f. Fish f. Coffee
g. Donut g. Juice g. Fish
h. Eggs h. Leftovers h. Green Vegetables
i. Fruit i. Lettuce i. Juice
j. Juice j. Margarine j. Margarine
k. Margarine k. Mayo k. Milk
l. Milk l. Meat l. Pasta
m. Oat Bran m. Milk m. Potato
n. Sugar n. Salad n. Poultry
o. Sweet Roll o. Salad Dressing o. Red Meat
p. Sweetener p. Sandwich p. Salad
q. Tea q. Soda q. Salad Dressing
r. Toast r. Soup r. Soda
s. Water s. Sugar s. Sugar
t. Wheat Bun t. Sweetener t. Sweetener
u. Yogurt u. Tea u. Tea
v. Other (List below) v. Tomato v. Water
w. Water w. White Rice
x. Yogurt x. Yellow Vegetables
y. Other (List below) y. Other (List below)
34. How much of the following do you consume each week?
35. Are you on a special diet? Yes____ No____ _____ ovo-lacto _____ vegetarian _____ diabetic _____ blood type
_____ diabetic _____ vegan _____ dairy restricted
_____ other (describe): ________________________________________________
36. Is there anything special about your diet that we should know? Yes____ No____ If yes, please explain: ____________________________________________________________________
37. Do you have symptoms immediately after eating, such as belching, bloating, sneezing, hives, etc.? Yes____ No____ If yes, are these symptoms associate with any particular food(s) or supplement(s)? Yes____ No____ If yes, please list the food(s) or supplement(s) and symptom(s): _______________________________________ ____________________________________________________________________________________________
38. Do you feel that you have delayed symptoms after eating certain foods (symptoms may not be evident for 24 hours or more), such as fatigue, muscle aches, sinus congestion, etc.? Yes____ No____
39. Do you feel much worse if you eat a lot of: ____ high fat foods ____ refined sugar (junk food) ____ high protein foods ____ fried foods ____ high carbohydrate foods ____ 1 or 2 alcoholic drinks
(breads, pastas, potatoes)
40. Do you feel much better if you eat a lot of: ____ high fat foods ____ refined sugar (junk food) ____ high protein foods ____ fried foods ____ high carbohydrate foods ____ 1 or 2 alcoholic drinks (breads, pastas, potatoes)
41. Does skipping a meal greatly affect your symptoms? Yes____ No____
42. Have you ever had a food that you really craved or really ”binged” on over a period of time? Yes____ No____
If yes, what food? ___________________________________________________________________
43. Have you ever had an aversion to certain foods? Yes____ No____ If yes, what food? ___________________________________________________________________
44. Please fill in the chart below about your bowel movements:
Frequency Consistency Color
More than 3 per day Soft and well formed Medium brown consistently
1-3 per day Often float Very dark or black
4-6 per week Difficult to pass Greenish color
2-3 per week Diarrhea Blood is visible
1 or fewer per week Thin, long and narrow Varies a lot
Small and hard Dark brown consistently
Loose but not watery Yellow, light brown
Alternating between hard and loose/watery
Greasy, shiny appearance
45. Intestinal gas: ____ Daily ____ Present with pain
____ Occasionally ____ Foul smelling ____ Excessive ____ Little Odor
47. Have you ever been pregnant? (If no, skip to question 53.) Yes____ No____ Number of miscarriages _____ Number of abortions _____ Number of preemies _____ Number of term births _____ Birth weight of largest baby _____ Smallest baby _____ Did you develop toxemia (high blood pressure)? Yes____ No____ Have you had other problems with pregnancy? Yes____ No____ If so, please comment: ___________________________________________________________________
_____________________________________________________________________________________ 48. Age at first period _____ Date of last Pap Smear __________ Date of last Mammogram____________ Pap Smear: ___ Normal ___Abnormal Mammogram: ___ Normal ___ Abnormal 49. Have you ever used birth control pills? Yes____ No____ If yes, when _________ 50. Are you taking the pill now? Yes____ No____ 51. Did taking the pill agree with you? Yes____ No____ Not applicable _____ 52. Do you currently use contraception? Yes____ No____ If yes, what type of contraception do you use? _______________________________________________ 53. Are you in menopause? No _____ Yes _____ If yes, age at last period______ Do you take: Estrogen?___ Ogen?___ Estrace?___ Premarin?___ Other (specify)___________ Progesterone?___ Provera? ___ Other (specify) _______________ 54. How long have you been on hormone replacement therapy (if applicable)? _________________ 55. In the second half of your cycle, do you have symptoms of breast tenderness, water retention, or irritability (PMS)?
